Survival for Nonshockable Cardiac Arrests Treated With Noninvasive Circulatory Adjuncts and Head/Thorax Elevation.

OBJECTIVES: Cardiac arrests remain a leading cause of death worldwide. Most patients have nonshockable electrocardiographic presentations (asystole/pulseless electrical activity). Despite well-performed basic and advanced cardiopulmonary resuscitation (CPR) interventions, patients with these presentations have always faced unlikely chances of survival. The primary objective was to determine if, in addition to conventional CPR (C-CPR), expeditious application of noninvasive circulation-enhancing adjuncts, and then gradual elevation of head and thorax, would be associated with higher likelihoods of survival following out-of-hospital cardiac arrest (OHCA) with nonshockable presentations. DESIGN: Using a prospective observational study design (ClinicalTrials.gov NCT05588024), patient data from the national registry of emergency medical services (EMS) agencies deploying the CPR-enhancing adjuncts and automated head/thorax-up positioning (AHUP-CPR) were compared with counterpart reference control patient data derived from the two National Institutes of Health clinical trials that closely monitored quality CPR performance. Beyond unadjusted comparisons, propensity score matching and matching of time to EMS-initiated CPR (TCPR) were used to assemble cohorts with corresponding best-fit distributions of the well-established characteristics associated with OHCA outcomes. SETTING: North American 9-1-1 EMS agencies. PATIENTS: Adult nontraumatic OHCA patients receiving 9-1-1 responses. INTERVENTIONS: In addition to C-CPR, study patients received the CPR adjuncts and AHUP (all U.S. Food and Drug Administration-cleared). MEASUREMENTS AND MAIN RESULTS: The median TCPR for both AHUP-CPR and C-CPR groups was 8 minutes. Median time to AHUP initiation was 11 minutes. Combining all patients irrespective of lengthier response intervals, the collective unadjusted likelihood of AHUP-CPR group survival to hospital discharge was 7.4% (28/380) vs. 3.1% (58/1,852) for C-CPR (odds ratio [OR], 2.46 [95% CI, 1.55-3.92]) and, after propensity score matching, 7.6% (27/353) vs. 2.8% (10/353) (OR, 2.84 [95% CI, 1.35-5.96]). Faster AHUP-CPR application markedly amplified odds of survival and neurologically favorable survival. CONCLUSIONS: These findings indicate that, compared with C-CPR, there are strong associations between rapid AHUP-CPR treatment and greater likelihood of patient survival, as well as survival with good neurological function, in cases of nonshockable OHCA.

Association of midazolam route of administration and need for recurrent dosing among children with seizures cared for by emergency medical services.

OBJECTIVE: National guidelines in the United States recommend the intramuscular and intranasal routes for midazolam for the management of seizures in the prehospital setting. We evaluated the association of route of midazolam administration with the use of additional benzodiazepine doses for children with seizures cared for by emergency medical services (EMS). METHODS: We conducted a retrospective cohort study from a US multiagency EMS dataset for the years 2018-2022, including children transported to the hospital with a clinician impression of seizures, convulsions, or status epilepticus, and who received an initial correct weight-based dose of midazolam (.2 mg/kg intramuscular, .1 mg/kg intravenous, .2 mg/kg intranasal). We evaluated the association of route of initial midazolam administration with provision of additional benzodiazepine dose in logistic regression models adjusted for age, vital signs, pulse oximetry, level of consciousness, and time spent with the patient. RESULTS: We included 2923 encounters with patients who received an appropriate weight-based dose of midazolam for seizures (46.3% intramuscular, 21.8% intranasal, 31.9% intravenous). The median time to the first dose of midazolam from EMS arrival was similar between children who received intramuscular (7.3 min, interquartile range [IQR] = 4.6-12.5) and intranasal midazolam (7.8 min, IQR = 4.5-13.4) and longer for intravenous midazolam (13.1 min, IQR = 8.2-19.4). At least one additional dose of midazolam was given to 21.4%. In multivariable models, intranasal midazolam was associated with higher odds (odds ratio [OR] = 1.39, 95% confidence interval [CI] = 1.10-1.76) and intravenous midazolam was associated with similar odds (OR = 1.00, 95% CI = .80-1.26) of requiring additional doses of benzodiazepines relative to intramuscular midazolam. SIGNIFICANCE: Intranasal midazolam was associated with greater odds of repeated benzodiazepine dosing relative to initial intramuscular administration, but confounding factors could have affected this finding. Further study of the dosing and/or the prioritization of the intranasal route for pediatric seizures by EMS clinicians is warranted.

Association Between Emergency Medical Service Agency Intubation Rate and Intubation Success.

STUDY OBJECTIVE: Airway management is a crucial part of out-of-hospital care. It is not known if the rate of overall agency intubation attempts is associated with intubation success. We sought to evaluate the association between agency intubation attempt rate and intubation success using a national out-of-hospital database. METHODS: We conducted a retrospective secondary analysis of the ESO Data Collaborative from 2018 to 2019, and included all adult cases with an endotracheal intubation attempt. We calculated the number of intubations attempted per 100 responses, advanced life support responses, and transports for each agency. We excluded cases originating at health care facilities and outliers. We used multivariable logistic regression to evaluate the association between agency intubation attempt rate and 1) intubation success and 2) first-pass success. We adjusted for confounders. RESULTS: We included 1,005 agencies attempting 58,509 intubations. Overall, the intubation success rate was 78.8%, and the first-pass success rate was 68.5%. Per agency, the median rate of intubation attempts per 100 emergency medical service responses was 0.8 (interquartile range 0.6 to 1.1). Rates of intubation attempts per 100 responses (adjusted odds ratio [aOR] 1.7; 95% confidence interval [CI] 1.6 to 1.8), advanced life support responses (aOR 1.18; 95% CI 1.16 to 1.20), and transports (aOR 1.21; 95% CI 1.18 to 1.22) were all associated with intubation success. These relationships were similar for first-pass success but with smaller effect sizes. CONCLUSION: Higher agency rates of intubation attempts were associated with increased rates of intubation success and first-pass success.

A National Study on the Comparative Burden of Pedestrian Injuries from Falls Relative to Pedestrian Injuries from Motor Vehicle Collisions.

Pedestrian injuries from falls are an understudied cause of morbidity. Here, we compare the burden of pedestrian injuries from falls occurring on streets and sidewalks with that from motor vehicle collisions. Data on injurious falls on streets and sidewalks, and pedestrian-motor vehicle collisions, to which Emergency Medical Services responded, along with pedestrian and incident characteristics, were identified in the 2019 National Emergency Medical Services Information System database. In total, 118,520 injurious pedestrian falls and 33,915 pedestrians-motor vehicle collisions were identified, with 89% of the incidents occurring in urban areas. Thirty-two percent of pedestrians struck by motor vehicles were coded as Emergent or Critical by Emergency Medical Services, while 19% of pedestrians injured by falls were similarly coded. However, the number of pedestrians whose acuity was coded as Emergent or Critical was 2.1 times as high for injurious falls as compared with pedestrians-motor vehicle collisions. This ratio was 3.9 for individuals 50 years and older and 6.1 for those 65 years and older. In conclusion, there has been substantial and appropriate policy attention given to preventing pedestrian injuries from motor vehicles, but disproportionately little to pedestrian falls. However, the population burden of injurious pedestrian falls is significantly greater and justifies an increased focus on outdoor falls prevention, in addition to urban design, policy, and built environment interventions to reduce injurious falls on streets and sidewalks, than currently exists across the USA.

A Retrospective Nationwide Comparison of the iGel and King Laryngeal Tube Supraglottic Airways for Out-of-Hospital Cardiac Arrest Resuscitation.

INTRODUCTION: While various supraglottic airway devices are available for use during out-of-hospital cardiac arrest (OHCA) resuscitation, comparisons of patient outcomes by device are limited. In this study, we aimed to compare outcomes of OHCA patients who had airway management by emergency medical services (EMS) with the iGel or King-LT. METHODS: We used the 2018-2021 ESO Data Collaborative public use research datasets for this retrospective study. All patients with non-traumatic OHCA who had iGels or King-LTs inserted by EMS were included. Our primary outcome was survival to discharge to home, and secondary outcomes included first-pass success, return of spontaneous circulation (ROSC), and prehospital rearrest. We examined the association between airway device and each outcome using two-level mixed effects logistic regression with EMS agency as the random effect, adjusted for standard Utstein variables and failed intubation prior to supraglottic airway insertion. Average treatment effects were calculated through propensity score matching. RESULTS: A total of 286,192 OHCA patients were screened, resulting in 93,866 patients eligible for inclusion in this analysis. A total of 9,456 transported patients (59.8% iGel) had associated hospital disposition data. Use of the iGel was associated with greater survival to discharge to home (aOR:1.36 [1.06, 1.76]; ATE: 2.2%[+0.5, +3.8]; n = 7,576), first pass airway success (aOR:1.94 [1.79, 2.09]; n = 73,658), and ROSC (aOR:1.19 [1.13, 1.26]; n = 73,207) in comparison to airway management with the King-LT. iGel use was associated with lower odds of experiencing a rearrest (aOR:0.73 [0.67, 0.79]; n = 20,776). Among patients who received a supraglottic device as a primary airway, use of the iGel was not associated with significantly greater survival to discharge to home (aOR:1.26 [0.95, 1.68]). Among patients who received a supraglottic device as a rescue airway following failed intubation, use of the iGel was associated with greater odds of survival to discharge to home (aOR:2.16 [1.15, 4.04]). CONCLUSION: In this dataset, use of the iGel during adult OHCA resuscitation was associated overall with better outcomes compared to use of the King-LT. Subgroup analyses suggested that use of the iGel was associated with greater odds of achieving the primary outcome than the King-LT when used as a rescue device but not when used as the primary airway management device.

External Validation of Empirically Derived Vital Signs in Children and Comparison to Other Vital Signs Classification Criteria.

OBJECTIVE: Various vital sign ranges for pediatric patients have differing utility in identifying children with serious illness or injury requiring immediate intervention. While commonly used ranges are derived from samples of healthy children, limited research has explored the utility of those derived from real-world encounters by emergency medical services (EMS). We first sought to externally validate pediatric vital sign ranges empirically derived from the prehospital setting. Second, we compared the proportion of children who received prehospital interventions using current common classification systems versus empirically derived vital sign ranges. METHODS: We retrospectively reviewed pediatric (<18 years) prehospital records from the 2021 ESO Collaborative dataset. We compared the proportions of encounters having vital signs (heart rate, respiratory rate, and systolic blood pressure) at the cutoffs of >99th, >95th, >90th, <10th, <5th and <1st centiles to previously reported centiles derived from EMS encounters in 2019-2020. We compared the deviation of mean Z-score by age between data sources. We identified the proportion of encounters with extreme (defined as <10th or >90th centile) vital signs who received prehospital interventions for the empirically derived criteria to six other classification criteria. RESULTS: 510,414 encounters were included, of which 66.9% were for medical indications and 70.7% resulted in hospital transport. The study sample had similar proportions of encounters identified at studied cutoffs compared to the previously published derivation sample, with all differences in proportions ≤1.1% between samples. All mean Z-scores were within 0.2 standard deviations of those from the derivation sample for each vital sign. Using empirically derived criteria, 34.2% had at least one extreme vital sign, compared to 69.1% with Pediatric Advanced Life Support criteria. Empirically derived extreme vital signs identified a higher proportion of children requiring most prehospital interventions compared to other vital signs criteria. CONCLUSION: Previously published empirically derived centiles for pediatric prehospital vital signs were replicated in this large multi-agency dataset. Compared to commonly used vital sign ranges, empirically derived criteria identified a higher proportion of children who received key prehospital interventions. Future steps include evaluating the role of these criteria in predictive models for in-hospital outcomes.

Mapping prehospital clinician impression to hospital-based diagnoses in children transported to the hospital by emergency medical services.

Objectives: Emergency medical services (EMS) serves a critical role in the delivery of services to children with out-of-hospital emergencies. The EMS clinicians' initial field diagnoses, termed "impressions", facilitate focused patient assessments, guide the application of prehospital treatment protocols, and help determine transport destination. We sought to evaluate the concordance of the EMS clinician impression to a child's hospital-based diagnosis.Methods: We retrospectively studied de-identified pediatric (<18 years old) scene runs transported to the hospital and with available linked hospital data from the 2021 ESO Data Collaborative, a multi-agency prehospital electronic health record dataset. EMS impressions and primary emergency department or admission-based diagnoses were categorized into one of twenty-one major groups in the Diagnosis Grouping System. We identified the most common hospital-based discharge diagnoses and evaluated for the agreement between EMS impression and hospital-based diagnosis using Cohen's Kappa statistic.Results: We included 35,833 pediatric transports from the scene with linked prehospital and in-hospital data (median age 11 years, interquartile range, 3-15 years; 50.9% male). The most common categories for both EMS impressions and hospital-based diagnoses were as follows respectively: trauma (26.1%; 24.6%), neurologic diseases (18.9%; 16.4%), psychiatric and behavioral diseases and substance use disorder (11.8%; 11.6%), and respiratory diseases (11.1% and 9.5%). A total of 23,224 out of 35,833 patients, or 64.8%, had concordant EMS impressions and hospital-based diagnoses. There was high agreement between common EMS impression and in-hospital diagnoses (trauma 77.3%; neurologic diseases 70.3%; respiratory diseases 64.5%; and psychiatric, behavioral disease and substance use disorder 73.9%). Hospital-based diagnoses demonstrated moderate concordance with prehospital data (Cohen's κ = 0.59).Conclusions: We found moderate concordance between EMS primary impression and hospital diagnoses. The EMS encounter is brief and without capabilities of advanced testing, but initial impressions may influence the basis of the triage assignment and interventions during the hospital-based encounter. By evaluating EMS impressions and ultimate hospital diagnoses, pediatric protocols may be streamlined, and specific training emphasized in pursuit of improving patient outcomes. Future work is needed to examine instances of discordance and evaluate the impact on patient care and outcomes.

Retrospective Comparison of Upper and Lower Extremity Intraosseous Access During Out-of-Hospital Cardiac Arrest Resuscitation.

OBJECTIVE: Intraosseous (IO) access is frequently utilized during the resuscitation of out-of-hospital cardiac arrest (OHCA) patients. Due to proximity to the heart and differential flow rates, the anatomical site of IO access may impact patient outcomes. Using a large dataset, we aimed to compare the outcomes of OHCA patients who received upper or lower extremity IO access during resuscitation. METHODS: The ESO Data Collaborative public use research datasets were used for this retrospective study. All adult (≥18 years of age) OHCA patients with successful IO access in an upper or lower extremity were evaluated for inclusion. Patients were excluded if they had intravenous (IV) access prior to IO access, or if they had a Do Not Resuscitate order documented. Our primary outcome was return of spontaneous circulation (ROSC). Secondary outcomes included survival to discharge and survival to discharge to home. Mixed-effects multivariable logistic regression models adjusted for age, sex, etiology, witnessed status, pre-first responder cardiopulmonary resuscitation (CPR), initial electrocardiogram (ECG) rhythm, location [private/residential, public, or assisted living/institutional], and response time in addition to the primary airway management strategy (endotracheal intubation, supraglottic device, surgical airway, no advanced airway) were used to compare the outcomes of patients with upper extremity IO access to the outcomes of patients with lower extremity IO access. RESULTS: After application of exclusion criteria, 155,884 patients who received IO access during resuscitation remained (76% lower extremity, 24% upper extremity). Upper extremity IO access was associated with greater adjusted odds of ROSC (1.11 [1.08, 1.15]), and this finding was consistent across multiple patient subgroups. Secondary analyses suggested that upper extremity access was associated with increased survival to discharge (1.18 [1.00, 1.39]) and survival to discharge to home (1.23 [1.02, 1.48]) in comparison to lower extremity IO access. CONCLUSION: In this large prehospital dataset, upper extremity IO access was associated with a small increase in the odds of ROSC in comparison to lower extremity IO access. These data support the need for prospective investigation of the ideal IO access site during OHCA resuscitation.

The Association of Combined Prehospital Hypotension and Hypoxia with Outcomes following Out-of-Hospital Cardiac Arrest Resuscitation.

BACKGROUND: Prehospital post-resuscitation hypotension and hypoxia have been associated with adverse outcomes in the context of out-of-hospital cardiac arrest (OHCA). We aimed to investigate the association between clinical outcomes and post-resuscitation hypoxia alone, hypotension alone, and combined hypoxia and hypotension. METHODS: We used the 2018-2021 ESO annual datasets to conduct this study. All EMS-treated non-traumatic OHCA patients who had a documented prehospital return of spontaneous circulation (ROSC) and two or more SpO2 readings and systolic blood pressures recorded were evaluated for inclusion. Patients who were less than 18 years of age, pregnant, had a do-not-resuscitate order or similar, achieved ROSC after bystander CPR only, or had an EMS-witnessed cardiac arrest were excluded. Multivariable logistic regression adjusted for standard Utstein factors and highest prehospital Glasgow Coma Scale (GCS) score was used to investigate the association between hypoxia, hypotension, and outcomes. RESULTS: We analyzed data for 17,943 patients, of whom 3,979 had hospital disposition data. Hypotension and hypoxia were not documented in 1,343 (33.8%) patients, 1,144 (28.8%) had only hypoxia documented, 507 (12.7%) had only hypotension documented, and 985 (24.8%) had both hypoxia and hypotension documented. In comparison to patients who did not have documented hypotension or hypoxia, patients who had documented hypoxia (aOR: 1.76 [1.38, 2.24]), documented hypotension (aOR: 3.00 [2.15, 4.18]), and documented hypoxia and hypotension combined (aOR: 4.87 [3.63, 6.53]) had significantly increased mortality. The relationship between mortality and vital sign abnormalities (hypoxia and hypotension > hypotension > hypoxia) was observed in every evaluated subgroup. CONCLUSIONS: In this large dataset, hypotension and hypoxia were independently associated with mortality both alone and in combination. Compared to patients without documented hypotension and hypoxia, patients with documented hypotension and hypoxia had nearly five-fold greater odds of mortality.

The Association of Prehospital End-Tidal Carbon Dioxide with Survival Following Out-of-Hospital Cardiac Arrest.

OBJECTIVE: End tidal carbon dioxide (ETCO2) is often used to assess ventilation and perfusion during cardiac arrest resuscitation. However, few data exist evaluating the relationship between ETCO2 values and mortality in the context of contemporary resuscitation practices. We aimed to explore the association between ETCO2 and mortality following out-of-hospital cardiac arrest (OHCA). METHODS: We used the 2018-2021 ESO annual datasets to query all non-traumatic OHCA patients with attempted resuscitation. Patients with documented DNR/POLST, EMS-witnessed arrest, ROSC after bystander CPR only, or < 2 documented ETCO2 values were excluded. The lowest and highest ETCO2 values recorded during the total prehospital interval, in addition to the pre- and post-ROSC intervals for resuscitated patients, were calculated. Multivariable logistic regression models adjusted for age, sex, initial rhythm, witnessed status, bystander CPR, etiology, OHCA location, sodium bicarbonate administration, number of milligrams of epinephrine administered, and response interval were used to evaluate the association between measures of ETCO2 and mortality. RESULTS: Hospital outcome data were available for 14,122 patients, and 2,209 (15.6%) were classified as surviving to discharge. Compared to patients with maximum prehospital ETCO2 values of 30-40 mmHg, odds of mortality were increased for patients with maximum prehospital ETCO2 values of <20 mmHg (aOR: 3.5 [2.1, 5,9]), 20-29 mmHg (aOR: 1.5 [1.1, 2.1]), and >50 mmHg (aOR: 1.5 [1.2, 1.8]). After 20 minutes of ETCO2 monitoring, <12% of patients had ETCO2 values <10 mmHg. This cutpoint was 96.7% specific and 6.9% sensitive for mortality. CONCLUSION: In this dataset, both high and low ETCO2 values were associated with increased mortality. Contemporary resuscitation practices may make low ETCO2 values uncommon, and field termination decision algorithms should not use ETCO2 values in isolation.

Measures of Patient Acuity Among Children Encountered by Emergency Medical Services by the Child Opportunity Index.

Background: Children have differing utilization of emergency medical services (EMS) by socioeconomic status. We evaluated differences in prehospital care among children by the Child Opportunity Index (COI), the agreement between a child's COI at the scene and at home, and in-hospital outcomes for children by COI. Methods: We performed a retrospective study of pediatric (<18 years) scene encounters from approximately 2,000 United States EMS agencies from the 2021-2022 ESO Data Collaborative. We evaluated socioeconomic status using the multi-dimensional COI v2.0 at the scene. We described EMS interventions and in-hospital outcomes by COI categories using ordinal regression. We evaluated the agreement between the home and scene COI. Results: Data were available for 99.8% of pediatric scene runs, with 936,940 included EMS responses. Children from lower COI areas more frequently had a response occurring at home (62.9% in Very Low COI areas; 47.1% in Very High COI areas). Children from higher COI areas were more frequently not transported to the hospital (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.86-0.87). Children in lower COI areas had lower use of physical (OR 1.23, 95% CI 1.13-1.33) and chemical (OR 1.41, 95% CI 1.29-1.55) restraints for behavioral health problems. Among injured children with elevated pain scores (≥7), analgesia was provided more frequently to children in higher COI areas (OR 1.73, 95% CI 1.65-1.81). The proportion of children in cardiac arrest was lowest from higher COI areas. Among 107,114 encounters with in-hospital data, the odds of hospitalization was higher among children from higher COI areas (OR 1.14, 95% CI 1.11-1.18) and was lower for in-hospital mortality (OR 0.75, 95% CI 0.65-0.85). Home and scene COI had a strong agreement (Kendall's W = 0.81). Conclusion: Patterns of EMS utilization among children with prehospital emergencies differ by COI. Some measures, such as for in-hospital mortality, occurred more frequently among children transported from Very Low COI areas, whereas others, such as admission, occurred more frequently among children from Very High COI areas. These findings have implications in EMS planning and in alternative out-of-hospital care models, including in regional placement of ambulance stations.

A National Assessment of EMS Performance at the Response and Agency Level.

BACKGROUND: In 2019, the National EMS Quality Alliance (NEMSQA) established a suite of 11 evidence-based EMS quality measures, yet little is known regarding EMS performance on a national level. Our objective was to describe EMS performance at a response and agency level using the National EMS Information System (NEMSIS) dataset. METHODS: The 2019 NEMSIS research dataset of all EMS 9-1-1 responses in the United States was utilized to calculate 10 of 11 NEMSQA quality measures. Measure criteria and pseudocode was implemented to calculate the proportion meeting measure criteria and 95% confidence intervals across all encounters and for each anonymized agency. We omitted Pediatrics-03b because the NEMSIS national dataset does not report patient weight. Agency level analysis was subsequently stratified by call volume and urbanicity. RESULTS: Records from 9,679 agencies responding to 26,502,968 9-1-1 events were analyzed. Run-level average performance ranged from 12% for Safety-01 (encounter documented as initial response without the use of lights and siren to 82% for Pediatrics-02 (documented respiratory assessment in pediatric patients with respiratory distress) At the agency level, significant variation in measure performance existed by agency size and by urbanicity. At the individual agency performance analysis, Trauma-04 (trauma patients transported to trauma center) had the lowest agency-level performance with 47% of agencies reporting 0% of eligible runs with documented transport to a trauma center. CONCLUSION: There is a wide range of performance in key EMS quality measures across the United States that demonstrate a need to identify strategies to improve quality and equity of care in the prehospital environment, system performance and data collection.

Dispatch Categories as Indicators of Out-of-Hospital Time Critical Interventions and Associated Emergency Department Outcomes.

OBJECTIVES: Emergency medical services (EMS) systems increasingly grapple with rising call volumes and workforce shortages, forcing systems to decide which responses may be delayed. Limited research has linked dispatch codes, on-scene findings, and emergency department (ED) outcomes. This study evaluated the association between dispatch categorizations and time-critical EMS responses defined by prehospital interventions and ED outcomes. Secondarily, we proposed a framework for identifying dispatch categorizations that are safe or unsafe to hold in queue. METHODS: This retrospective, multi-center analysis encompassed all 9-1-1 responses from 8 accredited EMS systems between 1/1/2021 and 06/30/2023, utilizing the Medical Priority Dispatch System (MPDS). Independent variables included MPDS Protocol numbers and Determinant levels. EMS treatments and ED diagnoses/dispositions were categorized as time-critical using a multi-round consensus survey. The primary outcome was the proportion of EMS responses categorized as time-critical. A non-parametric test for trend was used to assess the proportion of time-critical responses Determinant levels. Based on group consensus, Protocol/Determinant level combinations with at least 120 responses (∼1 per week) were further categorized as safe to hold in queue (<1% time-critical intervention by EMS and <5% time-critical ED outcome) or unsafe to hold in queue (>10% time-critical intervention by EMS or >10% time-critical ED outcome). RESULTS: Of 1,715,612 EMS incidents, 6% (109,250) involved a time-critical EMS intervention. Among EMS transports with linked outcome data (543,883), 12% had time-critical ED outcomes. The proportion of time-critical EMS interventions increased with Determinant level (OMEGA: 1%, ECHO: 38%, p-trend < 0.01) as did time-critical ED outcomes (OMEGA: 3%, ECHO: 31%, p-trend < 0.01). Of 162 unique Protocols/Determinants with at least 120 uses, 30 met criteria for safe to hold in queue, accounting for 8% (142,067) of incidents. Meanwhile, 72 Protocols/Determinants met criteria for unsafe to hold, accounting for 52% (883,683) of incidents. Seven of 32 ALPHA level Protocols and 3/17 OMEGA level Protocols met the proposed criteria for unsafe to hold in queue. CONCLUSIONS: In general, Determinant levels aligned with time-critical responses; however, a notable minority of lower acuity Determinant level Protocols met criteria for unsafe to hold. This suggests a more nuanced approach to dispatch prioritization, considering both Protocol and Determinant level factors.

Evidence-Based Guidelines for Prehospital Airway Management: Methods and Resources Document.

INTRODUCTION: Emergency airway management is a common and critical task EMS clinicians perform in the prehospital setting. A new set of evidence-based guidelines (EBG) was developed to assist in prehospital airway management decision-making. We aim to describe the methods used to develop these EBGs. METHODS: The EBG development process leveraged the four key questions from a prior systematic review conducted by the Agency for Healthcare Research and Quality (AHRQ) to develop 22 different population, intervention, comparison, and outcome (PICO) questions. Evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework and tabulated into the summary of findings tables. The technical expert panel then used a rigorous systematic method to generate evidence to decision tables, including leveraging the PanelVoice function of GRADEpro. This process involved a review of the summary of findings tables, asynchronous member judging, and online facilitated panel discussions to generate final consensus-based recommendations. RESULTS: The panel completed the described work product from September 2022 to April 2023. A total of 17 summary of findings tables and 16 evidence to decision tables were generated through this process. For these recommendations, the overall certainty in evidence was "very low" or "low," data for decisions on cost-effectiveness and equity were lacking, and feasibility was rated well across all categories. Based on the evidence, 16 "conditional recommendations" were made, with six PICO questions lacking sufficient evidence to generate recommendations. CONCLUSION: The EBGs for prehospital airway management were developed by leveraging validated techniques, including the GRADE methodology and a rigorous systematic approach to consensus building to identify treatment recommendations. This process allowed the mitigation of many virtual and electronic communication confounders while managing several PICO questions to be evaluated consistently. Recognizing the increased need for rigorous evidence evaluation and recommendation development, this approach allows for transparency in the development processes and may inform future guideline development.

Evidence-Based Guideline for Prehospital Airway Management.

Airway management is a cornerstone of emergency medical care. This project aimed to create evidence-based guidelines based on the systematic review recently conducted by the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel was assembled to review the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The panel made specific recommendations on the different PICO (population, intervention, comparison, outcome) questions reviewed in the AHRQ review and created good practice statements that summarize and operationalize these recommendations. The recommendations address the use of ventilation with bag-valve mask ventilation alone vs. supraglottic airways vs. endotracheal intubation for adults and children with cardiac arrest, medical emergencies, and trauma. Additional recommendations address the use of video laryngoscopy and drug-assisted airway management. These recommendations, and the associated good practice statements, offer EMS agencies and clinicians an opportunity to review the available evidence and incorporate it into their airway management strategies.

Achieving Equity in EMS Care and Patient Outcomes Through Quality Management Systems: A Position Statement.

Improving health and safety in our communities requires deliberate focus and commitment to equity. Inequities are differences in access, treatment, and outcomes between individuals and across populations that are systemic, avoidable, and unjust. Within health care in general, and Emergency Medical Services (EMS) in particular, there are demonstrated inequities in the quality of care provided to patients based on a number of characteristics linked to discrimination, exclusion, or bias. Given the critical role that EMS plays within the health care system, it is imperative that EMS systems reduce inequities by delivering evidence-based, high-quality care for the communities and patients we serve. To achieve equity in EMS care delivery and patient outcomes, the National Association of EMS Physicians recommends that EMS systems and agencies: make health equity a strategic priority and commit to improving equity at all levels.assess and monitor clinical and safety quality measures through the lens of inequities as an integrated part of the quality management process.ensure that data elements are structured to enable equity analysis at every level and routinely evaluate data for limitations hindering equity analysis and improvement.involve patients and community stakeholders in determining data ownership and stewardship to ensure its ongoing evolution and fitness for use for measuring care inequities.address biases as they translate into the quality of care and standards of respect for patients.pursue equity through a framework rooted in the principles of improvement science.

Remission of severe forms of long COVID following monoclonal antibody (MCA) infusions: A report of signal index cases and call for targeted research.

OBJECTIVE: Long COVID has afflicted tens of millions globally leaving many previously-healthy persons severely and indefinitely debilitated. The objective here was to report cases of complete, rapid remission of severe forms of long COVID following certain monoclonal antibody (MCA) infusions and review the corresponding pathophysiological implications. DESIGN: Case histories of the first three index events (among others) are presented. Unaware of others with similar remissions, each subject independently completed personal narratives and standardized surveys regarding demographics/occupation, past history, and the presence and respective severity grading of 33 signs/symptoms associated with long COVID, comparing the presence/severity of those symptoms during the pre-COVID, long-COVID, post-vaccination, and post-MCA phases. SETTING: Patient interviews, e-mails and telephone conversations. SUBJECTS: Three previously healthy, middle-aged, highly-functioning persons, two women and one man (ages 60, 43, and 63 years respectively) who, post-acute COVID-19 infection, developed chronic, unrelenting fatigue and cognitive impairment along with other severe, disabling symptoms. Each then independently reported incidental and unanticipated complete remissions within days of MCA treatment. INTERVENTIONS: The casirivimab/imdevimab cocktail. MEASUREMENTS AND MAIN RESULTS: Irrespective of sex, age, medical history, vaccination status, or illness duration (18, 8 and 5 months, respectively), each subject experienced the same complete remission of their persistent disabling disease within a week of MCA infusion. Each rapidly returned to normal health and previous lifestyles/occupations with normalized exercise tolerance, still sustained to date over two years later. CONCLUSIONS: These index cases provide compelling clinical signals that MCA infusions may be capable of treating long COVID in certain cases, including those with severe debilitation. While the complete and sustained remissions observed here may only apply to long COVID resulting from pre-Delta variants and the specific MCA infused, the striking rapid and complete remissions observed in these cases also provide mechanistic implications for treating/managing other post-viral chronic conditions and long COVID from other variants.

A Simpler Method for Choosing Adult i-gel Size: An Evaluation of Real-World Prehospital Data.

OBJECTIVE: The i-gel supraglottic airway device (Intersurgical, Berkshire, UK) is commonly used in the United States and worldwide for prehospital airway management. Previous research has suggested that a sex-based method of size selection (4.0 for female patients and 5.0 for male patients) is superior to a weight-based method in patients undergoing elective anesthesia. Our objective was to compare a sex-based i-gel size selection strategy with a weight-based strategy using real-world prehospital data. METHODS: The ESO Data Collaborative 2018 to 2022 dataset was used. All initial i-gel insertion attempts in patients > 18 years of age were evaluated for inclusion. Insertion attempts were excluded if age, sex, weight, success, or device size was not documented. Logistic regression was used to compare the rate of insertion failure on the first attempt for the group placed in alignment with the weight-based but not sex-based method with the group placed in alignment with the sex-based but not weight-based method. RESULTS: After the application of the exclusion criteria, 39,867 initial i-gel insertion attempts were included. The overall rate of failure was 6.5% (2,585/39,867). The rate of unsuccessful i-gel placement was similar when i-gel devices were placed in alignment with a sex-based size selection method in comparison to i-gel placement in alignment with a weight-based selection strategy (6.0% vs. 6.4%). Logistic regression analysis did not reveal a significant difference between groups (odds ratio: 1.08; 95% confidence interval: 0.95-1.23). CONCLUSION: The use of a sex-based method of i-gel size selection may be equivalent with respect to the rate of unsuccessful i-gel placement on the first attempt in comparison to a weight-based method.

Prehospital Stroke Care Part 1: Emergency Medical Services and the Stroke Systems of Care.

Acute stroke care begins before hospital arrival, and several prehospital factors are critical in influencing overall patient care and poststroke outcomes. This topical review provides an overview of the state of the science on prehospital components of stroke systems of care and how emergency medical services systems may interact in the system to support acute stroke care. Topics include layperson recognition of stroke, prehospital transport strategies, networked stroke care, systems for data integration and real-time feedback, and inequities that exist within and among systems.

Racial, Ethnic, and Socioeconomic Disparities in Out-of-Hospital Pain Management for Patients With Long Bone Fractures.

STUDY OBJECTIVE: To evaluate racial and ethnic disparities in out-of-hospital analgesic administration, accounting for the influence of clinical characteristics and community socioeconomic vulnerability, among a national cohort of patients with long bone fractures. METHODS: Using the 2019-2020 ESO Data Collaborative, we retrospectively analyzed emergency medical services (EMS) records for 9-1-1 advanced life support transport of adult patients diagnosed with long bone fractures at the emergency department. We calculated adjusted odds ratios (aOR) and 95% confidence intervals (CI) for out-of-hospital analgesic administration by race and ethnicity, accounting for age, sex, insurance, fracture location, transport time, pain severity, and scene Social Vulnerability Index. We reviewed a random sample of EMS narratives without analgesic administration to identify whether other clinical factors or patient preferences could explain differences in analgesic administration by race and ethnicity. RESULTS: Among 35,711 patients transported by 400 EMS agencies, 81% were White, non-Hispanic, 10% were Black, non-Hispanic, and 7% were Hispanic. In crude analyses, Black, non-Hispanic patients with severe pain were less likely to receive analgesics compared with White, non-Hispanic patients (59% versus 72%; Risk Difference: -12.5%, 95% CI: -15.8% to -9.9%). After adjustment, Black, non-Hispanic patients remained less likely to receive analgesics compared with White, non-Hispanic patients (aOR:0.65, 95% CI:0.53 to 0.79). Narrative review identified similar rates of patients declining analgesics offered by EMS and analgesic contraindications across racial and ethnic groups. CONCLUSIONS: Among EMS patients with long bone fractures, Black, non-Hispanic patients were substantially less likely to receive out-of-hospital analgesics compared with White, non-Hispanic patients. These disparities were not explained by differences in clinical presentations, patient preferences, or community socioeconomic conditions.